11:20 louvard - adjusting your level of competence to the difficulty of a cto
TRANSCRIPT
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Adjusting your level of competence to the difficulty of a CTO
Yves Louvard, Massy, France
Euro CTO club meeting, hotel Melia Castilla, Madrid, september 24-25, 2014
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How to adjust ?
• Adapt the patient difficulty to the skillness of the operator = patient selection
- predictors of success - scores - operator’s experience as a predictor of success
• In case of excessive difficulty - surgery (LM, LAD) ? - referral inside / outside the group - proctoring
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PCI of CTO’s and the Learning Curve
74 72 6760
70 7257
86
67
91
67
29 25
100
0102030405060708090
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Primary success rate (%)
% n= 292 250 118 77 76 72 49 22 12 11 9 7 4 1
Succes rate / operator: 2004-2009
ICPS CTO Database
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Success rates and failure predictors / years
Year n Success rate (%)
Previous CABG (%)
No visible stump (%)
Calcification (0-3)
Lesion length (mm)
2004 107 67.3 2.9 7.5 0.96+0.97 17.9+14.6
2005 165 67.9 4.3 16.6 1.07+1.01 18.7+13.2
2006 195 69.7 7.7 18.0 1.15+1.00 20.6+14.4
2007 178 68.5 8.4 22.9 0.92+0.98 22.7+21.2
2008 161 72.7 6.3 25.9 1.08+0.98 21.4+16.1
2009 194 73.2 8.4 32.5 0.86+1.09 23.2+19.8
ICPS CTO Database
PCI of CTO’s and the Learning Curve
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Patient’s selection
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Predictors of outcome
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Tortuosity <0.001 5.45 ( 2.05-14.51)Calcification 0.003 3.64 ( 1.56-8.48 )Bridging collateral 0.089 0.41 ( 0.14-1.15 )Long lesion 0.091 1.92 ( 0.90-4.07 )Abrupt type 0.161 1.92 ( 0.77-4.80 )Occl. Age (>3Mo) 0.409 1.68 ( 0.49-5.79 )Side branch 0.572 0.78 ( 0.33-1.86 )
Multivariate analysis of procedural failure
Determinants of procedural failure in CTO
Period IV P value Odds ratio (95% CI)
Mitsudo et al. CCT 2002
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Prospective Registry started in 2004 European CTO club definition Ischaemia and/or viability in the index territory Patients not considered for surgery as a 1st option 14 operators, Team approach CK measured 12-24 hours post PCI Lesion characteristics defined by one operator
ICPS Registry
PCI of CTO’s and the Learning Curve
ICPS CTO Database
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Predictors of Success / Failure of CTO PCIn= 1000
Success predictors: multivariate
OR 95% CI pNo visible stump 0.61 0.39-0.96 0.031Previous CABG 0.44 0.23-0.86 0.015Calcifications (0-3) 0.78 0.65-0.94 0.009Operator experience (1-6) 1.24 1.08-1.42 0.002Occlusion length (mm) 0.98 0.97-0.99 0.000
Louvard, Hayashida, ESC, AHA 2010
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Predictors of success in CTO PCI (1)
Successful PCI Univariate OR Multivariate OR Age(per 5 years increase)
0.96(0.89, 0.98)
p=0.009
0.94(0.89, 0.99)
p=0.048Lesion length(per 1 mm increase)
0.98(0.97, 0.98)
p<0.001
0.97(0.97, 0.98)
p<0.001Calcification(increasing thresholds of mild, mod-severe, and massive)
0.72(0.65, 0.80)
p<0.001
0.74(0.66, 0.84)
p<0.001No visible stump 0.66
(0.52, 0.85)p=0.001
0.62(0.46, 0.84)
p=0.002Tapered morphology 1.58
(1.26, 1.99)p<0.001
1.24(0.94, 1.63)
p=0.12
Leong, Louvard, ESC, AHA 2012
N= 1508
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Predictors of success in CTO PCI (2)
Successful PCI Univariate OR Multivariate OR Tortuosity 0.73
(0.56, 0.97)p=0.03
0.68(0.50, 0.93)
p=0.015Intraluminal channel 2.32
(1.59, 3.40)p<0.001
1.89(1.27, 2.83)
p=0.002Previous MI 0.60
(0.47, 0.78)p<0.001
0.66(0.50, 0.87)
p=0.003Previous CABG 0.40
(0.27, 0.58)p<0.001
0.42(0.28, 0.65)
p<0.001Operator experience(per 50 cases increase)
1.08(1.03, 1.13)
p=0.002
1.11(1.05, 1.18)
p=0.001
Leong, Louvard, ESC, AHA 2012
N= 1508
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Predictors of success in CTO PCI: Lesion length
Leong, Louvard, ESC, AHA 2012
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Higher Probability of Successful PCI in Patients With CTO of the LAD Compared to non LAD CTO PCI: Single Center Study
of 1,819 Consecutive Procedures
Alessandrino, Louvard, TCT 2014
Non LAD-CTO-PCI OR 95%CI P value
DM 0.6979 0.5277 to 0.9230 0.0117
Length>20 mm 0.4522 0.3489 to 0.5862 <0.0001
Severe Calcification 0.3523 0.2372 to 0.5233 <0.0001
Previous CABG 0.6152 0.4048 to 0.9349 0.0229
Previous MI 0.6903 0.5090 to 0.9360 0.0171
Tapered Stump 1.7297 1.3327 to 2.2450 <0.0001
LAD-CTO-PCI OR 95%CI P value
Dyslipidemia 0.5734 0.3560 to 0.9236 0.0222
Length>20 mm 0.5542 0.3496 to 0.8785 0.0120
Severe Calcification 0.4630 0.2453 to 0.8739 0.0175
Previous CABG 0.1039 0.0403 to 0.2682 <0.0001
Previous MI 0.5801 0.3477 to 0.9677 0.0370
Intra CTO tortuosity 0.4172 0.1859 to 0.9365 0.0341
LAD-CTO-PCI had a higher procedural success rate compared to non LAD (78.8% vs 69.7%, p<0.0001).
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Scores
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Morino et al. JACC Interv 2011; 4: 213-221
Wire crossing within less than 30 minutes
Predictors of success: the J-CTO score
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PCI sucess
Morino et al. JACC Interv 2011; 4: 213-221
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J-CTO score
%
P<0.001
Predictive value of the J-CTO score in percutaneous coronary interventions for chronic total occlusions: observed failure rate
Failure rate
Ferrante, Louvard, TCT 2012
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Predictive value of the J-CTO score in PCI for CTO: Predictive value of the J-CTO score
1.95
3.47
4.57
P=0.003
P<0.001
P<0.001
Ferrante, Louvard, TCT 2012
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Predictive value of the J-CTO score in PCI for CTO: Predictive value of the J-CTO score: discrimination
True
pos
itive
rate
False positive rate
AUC
0.77 (0.75-0.80) vs. 0.71 (0.69-0.74),P< 0.001
Ferrante, Louvard, TCT 2012
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Influence of case load on individual succes rate
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Learning Curve index
PCI of CTO’s and the Learning Curve
1: First 50 cases included in the study by 1 operator
2: 50 to 100
3: 100 to 150
4: 150 to 200
5: 200 to 250
6: > 250
ICPS CTO Database
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Multi-operator success / Case volume
Operator case volume categories
1481 CTO-lesions 1260 patients
% P=0.038
Tora Leong
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*
**
OR
of s
ucce
ss
* p=0.01 * * p<0.001† p= 0.014
2.1 (95% CI 1.2-3.7)
2.9 (95% CI 1.9-4.4)
†
J-CTO score
G. Ferrante, Y. Louvard, TCT 2012
Success rate of CTO PCI vs individual case load
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Patient’s selection: conclusion• Case load is a factor of success in CTO PCI: - dedicated operators - individual case selection - refer / refuse too « complex » patients - how to select patient: score, ideally including operator’s experience • But: - predictors of failure are changing, scores ? - case load influence on success rate is very unlikely to be linear and much probably vary between individuals - dedicated operators ?: how to traine new operators in new centers and more difficult in same center to face the case-load increase or operator retirement …
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How to improve the success rate in patients with CTO PCI ?
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IndividualSuccess Rate
Team Interaction
New TechniquesNew Devices
Patient selection
PCI of CTO’s and the Learning Curve
ICPS CTO Database
Case load
Intrinsic operator quality
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Impact of novel guide wire “Fielder XT” on CTO PCI success rate (ICPS, 2 operators)
Before Fielder XT After Fielder XT P
CTO n= 83 83
Fielder XT use (%) 1.2 80.7 0.000
Second attempt (%) 6.0 7.2 0.38
Procedural duration (min) 110 + 58 106 + 51 0.31
Contrast medium volume (cc) 258 + 137 290 + 147 0.08
Dissection (%) 24.7 12.2 0.02
Success rate (%) 67.5 84.3 0.005
Hayashida, Eur Heart J 2010; 31 (Suppl 1)
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- extensive didactic training - on-site proctorship- routine determination of case appropriateness- adherence to procedural safety guidelines- 2-operator/case approach
Team approach
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Proctoring, thanks to …
• Invited operators during local workshops (Japanese famous operators, Euro CTO members …)
• Invited operators for live transmissions (PCR, mainly on previously failed cases)
• « Private » proctoring for new devices ( James Spratt for StingRay and hybrid strategy, Peter O’Kane for Laser …)
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Database
• To individual success rate in well described lesions
• To know the procedural complications
• To help case distribution inside a group and referral outside
• To re validate the scores
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Overall PopulationUnivariate Analysis
Stepwise Logistic regression P<0.0001
Failure(455)
Success(1202)
p Odds Ratio 95% CI p
Hypertension, n (%) 301 (66,1) 694 (57,7) 0,0022 Previous MI n, (%) 128 (28,1) 224 (18,63) <0,0001 1,5633 1,1955 to 2,0443 0,0011
Previous PCI n, (%) 196 (43) 429 (35,7) 0,0067 Previous CABG n, (%) 58 (12,7) 66 (5,5) <0,0001 2,2809 1,5299 to 3,4005 0,0001
Multivessel CAD n, (%) 279 (61,3) 647 (53,8) 0,007 Non LAD n (%) 105 (23) 401 (33,3) <0,0001 1,5821 1,2135 to 2,0626 0,0007
Blunt Stump (%) 273 (60) 602 (50) 0,0004 1,5738 1,2444 to 1,9905 0,0002
Tortuous lesion n, (%) 84 (18,4) 167 (13,9) 0,009 Severe Calcification n, (%) 79 (17,3) 82 (6,8) <0,0001 2,9569 2,0815 to 4,2005 <0,0001
Lesion Lenght >20 mm n, (%) 214 (47) 366 (30,4) <0,0001 2,0480 1,6204 to 2,5884 <0,0001
Multivariable analysis
A Clinical And Angiographic Scoring system to predict the probability of successful first- attempt PCI in patients with total CTO
G. Allessandrino, T. Lefevre, Y. Louvard, submitted
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Independent Variables Odds Ratio Score
Severe Calcified lesion 2,95 + 2
Previous CABG 2,28 + 1,5
Lesion Length ≥ 20 mm 2.0 + 1,5
Previous MI 1,56 + 1
Blunt Stump 1,57 + 1
Non LAD CTO location 1,58 + 1
Independent predictive variables scored according to OR
A Clinical And Angiographic Scoring system to predict the probability of successful first- attempt PCI in patients with total CTO
G. Allessandrino, T. Lefevre, Y. Louvard, submitted
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Procedural success rate according to CL-SCORE value
A Clinical And Angiographic Scoring system to predict the probability of successful first- attempt PCI in patients with total CTO
G. Allessandrino, T. Lefevre, Y. Louvard, submitted
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Conclusions• Individual CTO case load and experience are factors of CTO
PCI success.
• To increase the institution success rate, selection of case based on actualized predictors and scores, selection of operator and team interaction / proctoring are important
• Database including lesion analysis, outcome, and individual success rate can be used to select the operators for specific cases
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